Ansonia Public Schools
Dyslexia Worksheet for Identification
(To be completed at Referral or Plan Re-evaluation PPT)
To be completed by the team at the PPT prior to recommending assessments for Learning Disability/Dyslexia.
Student Name: ______PPT Date: ______
Date student entered Ansonia Public Schools: ______
Cumulative days absent for 2 full school years in addition to current school year: ______
Cumulative days tardy for 2 full school years in addition to current school year: ______
1. Review the characteristics below at the referral PPT when a Learning Disability/Dyslexia is suspected by school staff and/or parent.
2. Check “Yes” if the characteristic is an area of concern.
3. Check “No” if the characteristic is not an area of concern.
4. Include any relevant comments or data to support the concern in the appropriate section.
5. If the team determines that the concern warrants further assessments, continue to review the attached assessment matrix to this document for team recommendations.
Characteristics: / Yes / No / Comments/DataFails to understand that words are composed of separate sound units.
Confusion of letters with similar sounds (i.e.: f/v)
Reversals and transpositions of letters and words with similar visual appearance (i.e.: b/d, was/saw)
Does not read fluently (choppy, slow, labored)
Relies on context to recognize a word
Avoids reading aloud in front of peers
Has difficulty with vocabulary
Comprehension above decoding level
Adequate comprehension of grade level text that is read to student
Difficulty pronouncing some multisyllabic words correctly (i.e.: multiplication)
Spelling the same word in different ways (i.e.: wuns, wunce, for once)
Writing may be disorganized and confusing to the reader
Has adequate ability to express self orally but written composition content appears to be below his/her potential.
Does not recognize a word just read when presented on the next page
Difficulty with memory
Difficulty with math calculation skills; recall of facts
Difficulty with word problems
Difficulty with learning words that rhyme
Difficulty with near or far point copying
SRBI Data Review:
Reading, Math, Writing Worksheets complete
Spelling, Writing, Math work sample attached
Classroom Assessments reviewed / DIBELS:
TRC/mCLASS:
Fountas and Pinnell Level:
Scholastic:
1. The PPT has determined that further assessments are warranted based on the number of concerns checked above, review of SRBI data, and review of reports from members of the PPT: _____YES ______NO
2. If YES is selected, review the assessments on the attached matrix and complete the Notice and Consent to Conduct an Initial Evaluation (ED625 October 2014) or the Notice and Consent to Conduct a Reevaluation (ED627 October 2014).
3. The Notice and Consent to Conduct an Initial Evaluation (ED625 October 2014) or the Notice and Consent to Conduct a Reevaluation (ED627 October 2014) has been completed and signed by the parent/guardian. ______YES ______NO
4. The results of the assessments will be reviewed at the Eligibility PPT on next Annual Review PPT scheduled for: ______
APS100/May 2016